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How to...take a federated approach to PBC

A PBC federation can help GPs share commissioning expertise and adopt a common approach to community-based services. Dr Joanne Medhurst, Dr Bill Cotter and Dr Tony McCullagh outline the benefits

A PBC federation can help GPs share commissioning expertise and adopt a common approach to community-based services. Dr Joanne Medhurst, Dr Bill Cotter and Dr Tony McCullagh outline the benefits

Taking a federated approach to PBC demands enormous energy, time and commitment. But taking this approach is proving its worth in our area, helping us pool ideas and resources and turn around the serious deficit faced by our local care trust.

Three locality groups situated close together in the borough of Bexley, Kent, had been established for 10 years but last year we recognised we needed a more effective working relationship between GP practices and the Bexley Care Trust.

In January 2007 a new chief executive, Mac McKeever, was brought into the care trust by chair Barbara Scott and met us – ‘we' are: Dr Joanne Medhurst, PBC lead for Frognal; Dr Bill Cotter, chair of Clocktower locality; and Dr Tony McCullagh, PBC lead for North Bexley.

Seeking a common approach to health needs

Recognising GP pride in our existing locality structures, Mac McKeever suggested we look at a federal model of working. We hoped to develop a common approach to health needs across Bexley and to provide a critical mass of a combined total of 220,000 patients, that would make changes in services more cost-effective.

With the locality structure already in place, developing the federal structure was quite straightforward – we launched it in February 2007 and it was approved and up and running a month later.

The care trust allocated the federation a fund of £420,000 for 2007/8, which is used to reimburse GP time and for some service redesign work – indeed, anything related to the PBC changes we've been making.

When we set up the federation we had to overcome apathy among some GP practices. To address this, the chief executive of the care trust and his deputy between them visited every practice to explain the new structure, and this personal touch was crucial in getting people on board.

The trust's PEC was looked at afresh to see how it could best support the federal approach and the federation leads were invited to sit on the executive team. Each federation lead identified a deputy – we asked for volunteers at a locality level – and each practice nominated a clinical lead and, in some localities, a practice manager lead.

We were surprised at how few obstacles there were to overcome. The LMC was initially cautious but during the past year we have involved LMC reps closely and valued their input and support.

As well as giving regular reports at LMC meetings, we hold wider meetings specifically discussing PBC, which are open to all practices and where we are available for questions and answers. Care trust managers attend LMC meetings as requested and ensure all significant developments are discussed with that team.

Federation fund reimburses GP time

The most demanding aspect of being a federation lead is time. We're allocated one day a week for federation business and paid £90 per hour from the care trust fund. This figure reflects not only the cost of paying for a locum GP for a day, but also the responsibility of the role. The care trust fund also supports PBC development and the work of lead GPs and deputies.

Representatives of our three localities meet as a federation twice a week. The three federation leads attend the PEC executive team meetings twice a month. One federation lead goes to the Bexley Care Trust board meetings and all of the leads go to the board development meetings.

Each locality attends a meeting twice a month, chaired by its federal lead and attended by PBC managers, to monitor performance and take forward service redesign.

During 2006/7, we developed a scheme whereby newly qualified GPs from the local vocational training scheme can work on a salaried contract with Bexley Care Trust.

This allows them to do a combination of clinical ‘backfill' where they act as regular locums to cover the appointments that are lost by the absence of the senior GPs leading on PBC and management work. The backfill support is critical to the success of the project because it means practices are not disadvantaged by the loss of a doctor.

Clinically driven round-table forums foster debate

From the care trust fund we give financial support – £80 per hour – to GPs leading one of the round tables. These are clinically driven forums where GPs and hospital colleagues from the seven hospitals across the federation debate moves to deliver more services in a community setting, closer to people's homes and by the most appropriate clinician.

One or two senior trust managers, along with a representative from each locality, also attend meetings to take forward action points and agree how services should change.

One result of these round-table discussions was the launch of an urgent care centre at St Mary's Hospital, Kent, which is run by local GPs, emergency nurse practitioners and healthcare assistants. The centre triages patients attending A&E who do not have life-threatening conditions. More than 60 people a day attend, with most seen within one hour.

On the large areas of work, such as cardiology, one locality agrees to lead talks in a round table and then shares its proposals with the other two. On smaller areas, such as rheumatology, a locality or a few clinicians develop a proposal that is then implemented for all.

There were some initial misgivings from GPs, but their fears were allayed once it became clear that the benefits would be shared equally.

Local incentive scheme for GPs

After some weeks of consultation with the LMC and the localities, a local incentive scheme was agreed. This gave practices the opportunity to share £1m by hitting targets for reducing prescribing levels and making more effective use of secondary care.

Prior to this, there were significant variations in the spend per patient between surgeries. Practices are now on target for a £1.4m saving on the prescribing budget. An in-house system of agreeing referrals for secondary care was also accepted. This has resulted in a 23% decrease in referrals.

Each practice has a budget for prescribing and secondary care and these are shared across each locality with 4% of the practices' indicative budgets held back and pooled for high-cost patients.

Traditionally the budgets were based on the previous year's spend, but the federation agreed to move from this to 25% capitation-based this year, 60% in 2008/9 and 100% in 2009/10. Budgets are allocated based on a formula that takes into account variations in population such as age ratios and deprivation scores.

We need strong and capable project managers to realise clinicians' aspirations, so this year we're hoping to develop an education programme to further enhance the skills of care trust managers and practice managers.

Patients have been involved as much as possible, for example in helping to reshape diabetes services. Practices have been encouraged to develop patient forums and each locality has regular meetings with patient representatives.

For patients, a federated approach means services are being developed consistently across the area. This has resulted in a community anti-coagulation service, and similar schemes for diagnostic cardiology and rheumatology.

Be flexible and demonstrate the benefits of change

All this work takes an enormous amount of time and energy so you need to be as flexible as possible. Meetings are scheduled across the week but cannot always fit around the clinical working practices of GPs.

You also need to be flexible in your thinking. PBC service redesign requires you to look at the clinical flows of patients, the clinicians providing the services, the buildings they are provided in and the wants and needs of the population. This requires imagination, flexibility and a certain amount of nerve.

And there are challenges to be faced. Developing the urgent care centre required considerable effort to overcome professional differences. Some practices have still to be persuaded about the value of service redesign and would prefer things to continue as they always have – but we maintain a regular dialogue with them.

You need to demonstrate the benefits of changes to the clinical service and the practice, give support when necessary and understand that change occurs at a different pace in different surgeries.

But the benefits make the work worthwhile. Pooling resources and expertise has strengthened the commissioning role, enabling significant savings to be made. Bexley is on target to save £1.4m on the prescribing budget and to reduce first outpatient appointments by 25%. Taking a federated approach has also given us a structure to provide effective community-based health services across the borough.

Working as a federation gives us the best of both worlds – preserving the identities of localities and making us stronger as a large commissioning group, which is crucial as provider services begin to shift from the acute sector to the community.

Dr Joanne Medhurst is a GP in Sidcup; Dr Bill Cotter is a GP in Welling; Dr Tony McCullagh is a GP in Thamesmead

All three are PBC federation leads in Bexley

For more information email them at joanne.medhurst@nhs.net or william.cotter@nhs.net or anthony.mccullagh@nhs.net

Dr Bill Cotter, Dr Tony McCullagh and Dr Joanne Medhurst are Bexley's federated leads Dr Bill Cotter, Dr Tony McCullagh and Dr Joanne Medhurst are Bexley's federated leads How the federation works

• The PBC federation in Bexley links
32 practices across three long-established localities
• The federation aims to pursue a common approach to PBC and service redesign for their combined patient population of 220,000 patients
• It received a £420,000 operating fund in 2007/8 from Bexley Care Trust to reimburse GP time on federation business and drive service redesign
• Three GPs act as federation leads and work one day a week on federation business – they are paid £90 per hour to cover locum costs and their federation duties
• The federation leads sit on the trust's
PEC executive team
• One federation lead attends the care trust's board meetings
• The federation holds clinical round tables attended by primary and secondary care doctors to debate and shape new services; GP chairs of these are paid £80 per hour for the work involved
• On large areas of work, one locality will produce, then share and roll out proposals to the other localities, to avoid duplication of effort and ensure a common approach
• A £1m incentive scheme has been set up for GPs to encourage better prescribing and reduce inappropriate use of secondary care
• Early achievements include the launch of an urgent care centre; Bexley is also on target to save £1.4m on prescribing budget and to reduce first outpatient appointments by 25%

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